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HAIR DONATION
Hair must be a minimum of 8 inches,
Clean, DRY, and in a ponytail(s) OR braid.
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
Place your DRY hair donation into a zip
lock bag and then in any mailing envelope.
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Please send this completed form along with
your hair donation to:
Children With Hair Loss
12776 Dixie Hwy • S. Rockwood, MI 48179
*A certificate of appreciation will be e-mailed or mailed to you. Please allow up to 10 weeks to receive your certificate.
(Print Clearly)
Name of Donor:
Email:
Phone:
Please provide your Email allowing us to send your certificate faster, save money and help more kids • International donors receive certificate by Email
Street Address:
Apt/Suite:
City:
State/Province/Region
(Optional) Print my certificate
In Memory Of
Zip/Postal Code
Country
In Honor Of:
Any Comments??
Did you include a picture?
Like Us on
Do we have your permission to publish it?
Facebook.com/CWHLMI • Follow Us on
Signature:
Twitter.com/CWHL_ORG and send us a photo and/or comment!!!
We appreciate your HAIR DONATION, but there is still a HUGE COST to have a hair replacement made.
Please consider contributing a tax deductible donation TODAY?
I HAVE ENCLOSED A $
DONATION TO HELP PAY FOR A CHILD’S HAIR REPLACEMENT
I HAVE ENCLOSED A $7 DONATION TO PAY FOR A HAT TO BE GIVEN TO A RECIPIENT OF CWHL
I HAVE ENCLOSED A
I HAVE ENCLOSED A
I HAVE ENCLOSED A
$25 DONATION
$30 DONATION
$20 DONATION
TO RECEIVE A T-SHIRT AND
HAIR DONATION PATCH
TO RECEIVE A T-SHIRT AND
ADJUSTABLE HEART BRACELET
TO RECEIVE A T-SHIRT
(Please select size and color of t-shirt)
SIZE:
Adult:
Youth Medium (Fits up to child size 8)
SM
MD
COLOR (Select One)
LG
Youth Large (Fits up to childe size 14)
XL
XXL
BLACK t-shirt
XXXL
XXXXL
PINK t-shirt
*If you live outside the United States your order must be placed through our website
www.ChildrenWithHairLoss.us
Checks may be made payable to: Children With Hair Loss
To have your donation charged to your credit card, please fill in your information below:
Payment Type:
Visa
Master Card
Discover
American Express
Credit Card Number:
Exp Date:
Name as it appears on card:
3 Digit Code on Back:
Signature of Cardholder: